A manual's draft reflects how diagnoses have grown foggier, drugs more ineffective
By EDWARD SHORTER
To flip through the latest draft of the American Psychiatric Association's Diagnostic and Statistical Manual, in the works for seven years now, is to see the discipline's floundering writ large. Psychiatry seems to have lost its way in a forest of poorly verified diagnoses and ineffectual medications. Patients who seek psychiatric help today for mood disorders stand a good chance of being diagnosed with a disease that doesn't exist and treated with a medication little more effective than a placebo.
Psychopharmacology, or the treatment of the mind and brain with drugs, has come to dominate the field. The positive side is that many illnesses respond readily to medication. The negative side is that the pharmaceutical industry seeks the largest possible market for a given drug, and advertises huge diseases, such as major depression and schizophrenia, the scientific status of which makes insiders uneasy.
In the 1950s and '60s, when psychiatry was still under the influence of the European scientific tradition, reasonably accurate diagnoses still sat at center stage. If you felt blue, uneasy and generally jumpy, "nerves" was a common diagnosis. For the psychotherapeutically oriented psychiatrists of the day, "psychoneurosis" was the equivalent of nerves. There was no point in breaking these terms down: clinicians and patients alike understood "a case of nerves," or a "nervous breakdown."
Our psychopathological lingo today offers little improvement on these sturdy terms. A patient with the same symptoms today might be told he has "social anxiety disorder" or "seasonal affective disorder." The increased specificity is spurious. There is little risk of misdiagnosis, because the new disorders all respond to the same drugs, so in terms of treatment, the differentiation is meaningless and of benefit mainly to pharmaceutical companies that market drugs for these niches.
For those more seriously ill, contemplating suicide or pacing restlessly and saying "It's all my fault," melancholia was the diagnosis of choice. The term has been around for donkey's years.
All the serious disorders of mood were once lumped together technically as "manic-depressive illness"—and again, there was little point in differentiating, because medications such as lithium that worked for mania were also sometimes effective in forestalling renewed episodes of serious depression.
Psychopharmacology—the treatment of disorders of the mind and brain with drugs—was experiencing its first big push, and a host of effective new agents was marketed. The first blockbuster drug in psychiatry appeared in 1955 as Wallace Lab's Miltown, a "tranquilizer" of the dicarbamate class. The first of the "tricyclic antidepressants" (because of their chemical structure) was launched in the U.S. in 1959, called imipramine generically and Tofranil by brand name. It remains today the single most effective antidepressant on the market for the immediate treatment of serious depression.
In the 1960s an entirely different class of drugs appeared, the benzodiazepines, indicated for anxiety rather than depression. (But one keeps in mind that these indications are more marketing devices than scientific categories, because most depression entails anxiety and vice versa.) In the benzodiazepine class, Librium was launched for anxiety in 1960, Valium in 1963. Despite an undeserved reputation for addictiveness, the benzos remain today one of the most useful drug classes in the history of psychiatry. They are effective across the entire range of nervous illnesses. In one World Health Organization study in the early 1990s, a sample of family physicians world-wide prescribed benzos for 28% of their depressed patients, 31% of their anxious patients; the figures are virtually identical. In the 1950s and '60s physicians had available drugs that truly worked for diseases that actually existed.
And then the golden era came to an end. The 1978 article of British psychiatrist Malcolm Lader on the benzos as "the opium of the masses" would be a good landmark. The patents expired for the drugs of the 1950s and '60s, and the solid diagnoses were all erased from the classification in 1980 with the appearance of the third edition of the DSM series, called "DSM-III." It was largely the brainchild of Columbia University psychiatrist Robert Spitzer, an energetic and charismatic individual who had been schooled in psychometrics. But his energy and charisma nearly led psychiatry off a cliff.
Mr. Spitzer was discouraged with psychoanalysis, and wanted to come up with a new illness classification that would ditch all the old Freudian concepts such as "depressive neurosis" with their implication of "unconscious psychic conflicts." Mr. Spitzer and company wanted diagnoses based on observable symptoms rather than on speculation about the unconscious mind. So he, and members of the Task Force that the American Psychiatric Association designated, set out to devise a new list of diagnoses that correspond to natural disease entities.
Yet Mr. Spitzer ran smack against the politics of the American Psychiatric Association, still heavily influenced by the psychoanalysts. Mr. Spitzer proposed such diagnoses as "major depression" and "dysthymia," diagnoses that were themselves highly heterogeneous, lumping together a number of different kinds of depression. But the terms turned out to be politically acceptable.
So in DSM-III there was a lot of horse-trading. The biologically oriented young Turks got a depression diagnosis—major depression—that was divorced from what they considered the psychoanalytic mumbo-jumbo. And the waning but still substantial number of analysts got a diagnosis—dysthymia—that sounded like their beloved "neurotic depression," that had been the mainstay of psychoanalytic practice. Psychiatry ended up with two brand-new depression diagnoses with criteria so broad that huge numbers of people could qualify for them.
There was one more bow to psychoanalysis: DSM-III continued to make depression separate from anxiety (because the analysts thought anxiety the motor that drove everything). And in homage to several influential figures in European psychiatry, DSM-III brought in "bipolar disorder," a condition alternating between depression and mania thought separate from "major depression."
A word of explanation: The evidence is very strong that the depression of "major depression" and the depression of "bipolar disorder" are the same disease. Experienced clinicians know that in chronic depressive illness many patients will have an episode of mania or hypomania; it is implausible that such an event would change the patient's diagnosis completely from "major depression" to "bipolar disorder," given that they are classified as quite different illnesses.
These rather technical issues in the classification of disease had enormous ramifications in the real world. Bipolar disorder became divorced from unipolar disorder. And anxiety—the original indication for the benzos—became soft-pedaled because the benzos were thought, incorrectly, to be highly addictive, and anxiety became associated with addiction.
Major depression became the big new diagnosis in the 1980s and after, replacing "neurotic depression" and "melancholia," even though it combined melancholic illness and non-melancholic illness. This would be like incorporating tuberculosis and mumps into the same diagnosis, simply because they are both infectious diseases. As well, "bipolar disorder" began its relentless on-march, supposedly separate from plain old depression.
New drugs appeared to match the new diseases. In the late 1980s, the Prozac-type agents began to hit the market, the "SSRIs," or selective serotonin reuptake inhibitors, such as Zoloft, Paxil, Celexa and Lexapro. They were supposedly effective by increasing the amount of serotonin available to the brain.
The SSRIs are effective for certain indications, such as obsessive-compulsive disorder and for some patients with anxiety. But many people believe they're not often effective for serious depression, even though they fit wonderfully with the heterogeneous concept of "major depression." So, hand in hand, these antidepressants and major depression marched off together into the sunset. These were drugs that don't work for diseases that don't exist, as it were.
The latest draft of the DSM fixes none of the problems with the previous DSM series, and even creates some new ones.
A new problem is the extension of "schizophrenia" to a larger population, with "psychosis risk syndrome." Even if you aren't floridly psychotic with hallucinations and delusions, eccentric behavior can nonetheless awaken the suspicion that you might someday become psychotic. Let's say you have "disorganized speech." This would apply to about half of my students. Pour on the Seroquel for "psychosis risk syndrome"!
DSM-V accelerates the trend of making variants on the spectrum of everyday behavior into diseases: turning grief into depression, apprehension into anxiety, and boyishness into hyperactivity.
If there were specific treatments for these various niches, you could argue this is good diagnostics. But, as with other forms of anxiety-depression, the SSRIs are thought good for everything. Yet to market a given indication, such as social-anxiety disorder, it's necessary to spend hundreds of millions of dollars on registration trials to convince the FDA that your agent works for this disease that previously nobody had ever heard of.
DSM-V is not all bad news. It turns the jumble of developmental syndromes for children into a single group of "autism spectrum disorders," which makes sense because previously, with Asperger's as a separate disease, it was like trying to draw lines in a bucket of water. But the basic problems of the previous DSM series are left untouched.
Where is psychiatry headed? What the discipline badly needs is close attention to patients and their individual symptoms, in order to carve out the real diseases from the vast pool of symptoms that DSM keeps reshuffling into different "disorders." This kind of careful attention to what patients actually have is called "psychopathology," and its absence distinguishes American psychiatry from the European tradition. With DSM-V, American psychiatry is headed in exactly the opposite direction: defining ever-widening circles of the population as mentally ill with vague and undifferentiated diagnoses and treating them with powerful drugs.
—Edward Shorter is professor of the history of medicine and psychiatry in the Faculty of Medicine of the University of Toronto. His latest book, written with Max Fink, "Endocrine Psychiatry: Solving the Riddle of Melancholia," is forthcoming from Oxford University Press.
Saturday, July 3, 2010
from Wall Street Journal on-line: